Pete Setabutr

MR imaging of orbital inflammatory syndrome, orbital cellulitis, and orbital lymphoid lesions: the role of diffusion-weighted imaging.

BACKGROUND AND PURPOSE: Orbital inflammatory syndrome (OIS) has clinical features that overlap with orbital lymphoid lesions and orbital cellulitis. Prompt diagnosis is needed in all 3 conditions because the management of each one differs greatly. CT and MR imaging, though useful, do not always distinguish among these conditions. The aim of this study was to identify the role of diffusion-weighted imaging (DWI) in differentiating these 3 diagnoses. MATERIALS AND METHODS: A retrospective analysis of orbital MR imaging was conducted. T1- and T2-weighted and postcontrast images were analyzed. Region-of-interest analysis was performed by using measurements in areas of abnormality seen on conventional MR imaging sequences and measurements of the ipsilateral thalamus for each patient. The DWI signal intensity of the lesion was expressed as a percentage of average thalamic intensity in each patient. Similarly, lesion apparent diffusion coefficients (ADCs) and lesion-thalamus ADC ratios were calculated. Statistical significance was determined by the Kruskal-Wallis test, and post hoc pairwise comparisons, by the Mann-Whitney U test for DWI-intensity ratio, ADC, and ADC ratio. RESULTS: A significant difference was noted in DWI intensities, ADC, and ADC ratio between OIS, orbital lymphoid lesions, and orbital cellulitis (P < .05). Lymphoid lesions were significantly brighter than OIS, and OIS lesions were significantly brighter than cellulitis. Lymphoid lesions showed lower ADC than OIS and cellulitis. A trend was seen toward lower ADC in OIS than in cellulitis (P = .17). CONCLUSIONS: DWI may help differentiate OIS from lymphoid lesions and cellulitis and may allow more rapid management.

Current ptosis management: a national survey of ASOPRS members.

Purpose: To assess current practice patterns for management of ptosis by current ASOPRS members. Methods: An invitation to participate in a web-based, anonymous survey was sent to current members of the American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) via e-mail. The survey consisted of 4 sections: preoperative testing of ptosis patients, surgical preferences, dry eye evaluation in ptosis patients, and length of postfellowship practice. Responses were analyzed using standard statistical methods. Results: Fifty percent of ASOPRS members performed more than 100 ptosis procedures in the past year. Most ASOPRS members performed preoperative photography, automated perimetry testing, and phenylephrine testing in evaluation of ptosis patients. A slight majority of ASOPRS members did not use preoperative Schirmer testing as the primary screening tool for dry eye disease. Most ASOPRS members performed internal levator aponeurosis advancement surgery, although most surgeons performing concurrent ptosis repair and blepharoplasty preferred an external approach. Frontalis sling surgery was performed using a wide variety of materials for suspension. Conclusion: Current trends in the management and preoperative evaluation of blepharoptosis by ASOPRS members revealed a number of interesting common practices that are of value to current practitioners.

Surgical microanatomy of the Müller muscle-conjunctival resection ptosis procedure

Purpose: To assess for alterations in the microscopic anatomy that occur as a result of the Müller muscle-conjunctival resection (MMCR) ptosis procedure and to better understand the mechanisms by which MMCR elevates the eyelid. Methods: Sixteen orbits from 8 fresh frozen Caucasian cadaver heads, ranging from 38 to 100 years of age were used. For each head, MMCR was performed on one side. The contralateral, unoperated orbit served as an anatomic control. Each exenterated orbital contents and excised MMCR specimen was evaluated. The histopathology of the eyelids and MMCR specimens were studied microscopically by staining with hematoxylin-eosin, elastic, and Verhoeff-Masson trichrome. Results: Müller muscle and conjunctiva were present in all 8 of the excised MMCR specimens. Elastic fibers consistent with Müller muscle tendon or among the smooth muscle fibers were seen within all excised MMCR specimens. The levator aponeurosis was intact in 8 of 8 operated eyelids; however, the aponeurosis was plicated in all. The accessory lacrimal gland tissues were intact in all of the operated and unoperated eyelids. Conclusions: MMCR works by shortening the posterior lamella, which results in advancement of the levator palpebrae superioris muscle and plication of the levator aponeurosis. Plication of the levator aponeurosis likely contributes to the increased volumetric effect seen clinically after MMCR. Phenylephrine testing can help in fine-tuning the amount of resection, but given the mechanism of action of MMCR, adequate levator muscle function remains a critical factor in the success of the surgery. Moreover, MMCR preserves accessory lacrimal gland tissues.

Epidemiological trends in malignant lacrimal gland tumors.

Objective To describe epidemiological trends in lacrimal gland malignancies in the United States. Study Design Retrospective database review. Setting Multicenter registry. Subjects and Methods A total of 702 malignant tumors of the lacrimal gland from the Surveillance, Epidemiology, and End Results database were included in the study. Disease-specific and overall survival were the primary outcome measures. Kaplan-Meier survival curves were generated for multiple patient and tumor characteristics, including race, histology, TNM tumor stage, age at diagnosis, radiotherapy, gender, and tumor grade. Cox proportional hazards regression was performed to assess the impact of patient and tumor characteristics on survival. Results Lymphoma (58.0%), adenoid cystic carcinoma (13.4%), adenocarcinoma (3.8%), and mucoepidermoid carcinoma (3.6%) accounted for most tumors. Lymphoma was associated with more favorable survival rates, while adenocarcinoma, adenoid cystic carcinoma, and mucoepidermoid carcinoma were associated with worse prognosis. There was a steady increase in the proportion of lymphoma diagnosed since 1973. In a multivariate Cox proportional hazards regression model, tumor histology remained as the only covariate correlated with disease-specific survival. Conclusion Patient characteristics and survival rates differ between lymphoma, adenoid cystic carcinoma, adenocarcinoma, and mucoepidermoid carcinoma. The proportion of lacrimal gland cancer diagnosed as lymphoma has steadily increased over time. Cox proportional hazards regression analysis demonstrated tumor histology as one of the most important factors in patient survival. These results augment our understanding of the expected disease course of lacrimal gland malignancies.

Evisceration and enucleation: a national survey of practice patterns in the United States.

BACKGROUND AND OBJECTIVE The management of evisceration and enucleation has changed over time. The authors assessed the practice patterns regarding eye removal among oculoplastic surgeons. PATIENTS AND METHODS Internet-based surveys were sent to American Society of Ophthalmic Plastic and Reconstructive Surgeons members regarding preferences in evisceration and/or enucleation, including indications, surgical techniques, preoperative evaluation modalities, implant types used, and postoperative complications experienced. RESULTS Surgeons who recently completed fellowship training are more likely to perform eviscerations than their senior counterparts. The variety of viable implant types and the use of enucleation or evisceration for certain indications were not always in concordance with historical guiding principles. However, changing trends are in line with the current literature. CONCLUSION Current practice patterns reflect recent literature and historical trends.

Relative Incidence of Blepharoptosis Subtypes in an Oculoplastics Practice at a Tertiary Care Center

Abstract Purpose: In patients referred with blepharoptosis, the possibility of an underlying systemic cause for their ptosis can warrant a more detailed evaluation. The purpose of this study is to determine both the incidence and demographic characteristics associated with different types of ptosis in patients referred to the oculoplastics division at a tertiary care center. Methods: A retrospective chart review was performed on all patients referred to the oculoplastics division between 2007 and 2010. Final etiology for each patient’s ptosis was determined based on history, standard eyelid measurements, and ancillary testing. Based on etiology, ptosis was categorized as aponeurotic, neurogenic, myogenic, traumatic, congenital, or mechanical. Demographics, including median age and sex were analyzed for patients in each category of ptosis. Results: Of the 251 patients, aponeurotic ptosis was the most common type of ptosis (60.2%), followed by traumatic (11.2%), congenital (10.4%), mechanical (8.8%), neurogenic (5.6%), and myogenic (4.0%). Of the neurogenic group, 35.7% of patients had cranial nerve 3 (CN 3) palsy, 28.6% had myasthenia gravis, 14.3% had aberrant regeneration, and 7.1% had Horner’s syndrome. Thirty percent of the myogenic group had chronic progressive external ophthalmoplegia (CPEO). The congenital group had the youngest median age (10.5 years), yet the aponeurotic group had the oldest (62 years). Conclusions: A significant proportion of patients referred with ptosis had more serious conditions such as neurogenic or myogenic ptosis. Thus, clinicians should maintain a high degree of suspicion and thoroughly evaluate all patients with ptosis in order to properly assess for underlying systemic associations.

Eyelid procedures in patients who have undergone Boston keratoprosthesis surgery.

Purpose: Artificial corneas or keratoprostheses such as the Boston keratoprosthesis (KPro) are being used more frequently to provide a clear corneal window in patients with severe corneal disease. A significant percentage of patients who undergo Boston KPro implantation require subsequent eyelid surgery. However, few articles in peer-reviewed literature evaluate the indication and outcome of eyelid procedures after Boston KPro implantation. This study examines the frequency, nature, and outcomes of oculoplastic procedures in patients with Boston KPro implantation. Methods: A retrospective chart review was conducted of all KPro-1 procedures performed at the University of Illinois at Chicago between December 2006 and September 2010 and all KPro-1 and KPro-2 procedures performed at the University of Iowa between December 2008 and October 2010. Results: One hundred and twenty eyes underwent Boston KPro-1 procedures, and 2 eyes underwent Boston KPro-2 procedures. Twenty-one (17.2%) of the 122 eyes required subsequent eyelid alterations. Chemical burn was the most common preoperative corneal diagnosis (8 of 21; 38.1%). A variety of oculoplastic procedures were performed; the most common procedure was a permanent lateral tarsorrhaphy. Seventeen (81.0%) of 21 KPro eyes that underwent oculoplastic procedures maintained the KPro at an average of 12.4 months of follow up. Conclusions: A significant number of patients with Boston KPros require subsequent eyelid surgery. With limited existing literature and increasing popularity for using Boston KPros to treat severe corneal disease, it is essential for oculoplastic and corneal surgeons to understand the need for eyelid alterations in these patients and the surgical intricacies surrounding these cases.

Review of ocular manifestations of nevoid basal cell carcinoma syndrome: What an ophthalmologist needs to know

Nevoid basal cell carcinoma syndrome (NBCCS) is a rare, autosomal dominant disorder characterized by multiple basal cell carcinomas (BCCs), odontogenic keratocysts, palmar and/or plantar pits, and ectopic calcifications of the falx cerebri. Myriad ophthalmologic findings are associated with NBCCS, including periocular BCCs, hypertelorism, strabismus, myelinated nerve fibers, and disorders of the retina and retinal pigment epithelium. We performed a literature search in PubMed for articles on the ophthalmologic manifestations of Gorlin syndrome, published between 1984 and 2014. Of 33 papers, 31 were included. Although Gorlin syndrome is due to mutations in a single gene, it displays variable phenotypic expressivity. Therefore, familiarity with this disorder across clinical specialties is necessary to avoid misdiagnosis. The ophthalmologist should be included in the multidisciplinary team for the management of Gorlin syndrome in order to prevent visual loss and improve the quality of life of these patients.

Periocular capillary hemangiomas: Indications and options for treatment

Capillary hemangiomas are the most common periocular and orbital tumors of childhood that typically arise in infancy. Though the diagnosis is frequently made on clinical examination, various diagnostic modalities may be helpful in initial evaluation and follow-up. Tests may be necessary in diagnosing suspect cases or aid in the differentiation of potential malignant tumors. In the vast majority of cases these tumors undergo spontaneous involution without sequelae. However, some periocular and orbital capillary hemangiomas require intervention to prevent serious complications. Other tumors require treatment to lessen the surgical burden for cosmetic repair. When treatment is necessary, there are a number of therapeutic options available. As there is no standard, potential risks and benefits must be discussed with the family and treatment should be specific in each case. A complete understanding of the natural history of the tumor, indications for treatment, and response to different therapies is imperative in managing this common lesion.

The effects of topical moxifloxacin 0.5% ophthalmic solution and gatifloxacin 0.3% solution on corneal healing after bilateral photorefractive keratectomy

Purpose: This study was designed to evaluate the effects of topical moxifloxacin 0.5% ophthalmic solution (Vigamox) and gatifloxacin 0.3% ophthalmic solution (Zymar) on corneal wound healing for patients undergoing bilateral photorefractive keratectomy (PRK). Methods: Forty-three patients with low-to-moderate myopia (−1.00 to −7.00 D), ranging from 21 to 71 years of age, were randomized into 2 groups: moxifloxacin (n = 21) and gatifloxacin (n = 22). After bilateral PRK, antibiotics were administered in both eyes (fellow-eye design) immediately and then every 6 hours until complete wound healing had occurred. Slit-lamp fluorescein pictures were taken of each eye immediately after surgery and on postoperative days until complete wound healing had taken place. NIH software (Image J) was used to measure surface area of the defect. Results: Analysis showed no difference in the time of wound closure (P = 0.79). The mean healing rate for moxifloxacin was 0.8 mm2/h ± 0.2 (mean ± standard deviation), and 0.8 mm2/h ± 0.2 for gatifloxacin. There were no differences in the healing rates (P = 0.61), haze (P > 0.09), or in the postoperative uncorrected visual acuity (P > 0.66) at 1 month. Conclusion: Moxifloxacin 0.5% ophthalmic solution and gatifloxacin 0.3% ophthalmic solution produced similar results with respect to haze, visual acuity, and rate of corneal wound healing when administered to PRK patients.